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Multidisciplinary care teams surround members with support

March 21, 2018 | Community


In Arizona, a member was struggling with obesity and severe lower back pain, while also serving as the sole provider for her family and the primary caregiver for her grandmother, who has Alzheimer’s Disease. Navigating the health care system and trying to achieve her health goals was difficult.

The multidisciplinary care team, a new Aetna program aimed at helping members with complex health problems break down barriers to access care, was the answer. The teams, which are fully integrated with providers in the community, help high-risk members with various health and social needs, from chronic disease management to access to transportation.

“Doctors are seeing the value of this care model and are recommending the program to their patients,” said Brigitte Nettesheim, vice president of transformative markets in Consumer Health & Services. “We’re hearing powerful anecdotes about what a difference this approach is making in people’s lives.”

The program is currently being offered by Texas Health Aetna, Banner|Aetna and Innovation Health.


For the member in Arizona, the multidisciplinary care team helped get her the care she needed and connected her with resources in the community to help care for her grandmother. A nurse case manager referred her to a local diabetes educator, connected her to a new primary care doctor and specialist and signed her up for aquatic exercise classes to help with weight loss and back pain.

The result of Aetna’s holistic approach to care has been nothing short of life changing, according to the member.

“I was feeling so overwhelmed and hopeless when I received that first call from the care team that I didn’t know where to begin,” she said. “I feel like an angel has answered my prayers.”

As part of a multidisciplinary care team, local nurse case managers, social workers, pharmacists, diabetes educators, certified medical assistants and medical directors analyze data to proactively identify and solve member needs. For example, nurse case managers talk with members face-to-face and by phone to help them find the care and community-based resources they need.

Multidisciplinary care teams do not provide medical care to members; instead, they help members get the care they need.

“This program is very much a local strategy to engage with our members,” said Catherine Czarnecki, executive director of Clinical Transformation in Joint Venture Markets for Aetna. “It meets people where they are in their health journeys.”